Work and cancer

Dr Richard PreeceConsultant in occupational medicine

Fellow, National Institute for Health and Clinical Excellence

18 October 2012

Agenda

• Cancer incidence and prevalence

• Work consequences of cancer

• Patient experiences

• Advising patients

• Improving support

Question 1

Three years after diagnosis of endometrial cancer women are:

• About 15% more likely to be in employment

• About as likely as others to be in employment

• About 15% less likely to be in employment

• About 30% less likely to be in employment

Question 2

Which of the following did not die from a malignant mesothelioma?

• John MacDougall, MP

• Malcolm McLaren, Musician

• Steve McQueen, Actor

• Bob Marley, Musician

Cancer attributable to occupation

• 5.3% deaths attributable

• Asbestos 4000• Silica 800• Diesel exhaust 650• Mineral oils 600• Shift work 550

Registrations:10000 men + 3600 women

Incidence (20-64)

• 97000 cases (37% of cancers in all age groups)

• 57% female

• 55% >55 years old• 82% >45 years old

• Commonest <30 years old = testis• Commonest at all ages >30 years = breast• >1/3 of all cases in 35-55 years old = breast

Incidence (20-64)

1. Breast 23000

2. Colon 9000

3. Prostate 8800

4. Lung 8400

5. Melanoma 5800

6. NH Lymphoma 4100

7. Mouth/pharynx 3400

8. Endometrium 3000

9. Kidney 2700

10. Ovary 2600

11. Leukaemia 2200

12. Oesophagus 2000

• ~1/2 of female is breast• ~1/4 of male is prostate• ~1/4 of male is colon+lung

Prevalence

(Maddams et al British Journal of Cancer (2009) 101, 541 – 547)

Risk of unemployment

• 61,626 cancer survivors • 356,484 healthy controls

• increased risk of unemployment (RR: 1.41 95%CI, 1.23- 1.62)

• but… significant heterogeneity

(Wells M et al (2011) CSO Report CZG/2/467)

Risk of (un)employment

No. Employed RR No. Employed RRLung 279 19% 0.45 Uterus 548 42% 0.84CNS 878 45% 0.66 Prostate 240 30% 0.87Leukaemia 222 45% 0.70 Colon 538 53% 0.90Stomach 284 38% 0.71 Kidney 404 50% 0.91NHL 411 49% 0.75 Breast 4098 61% 0.95Cervix 183 58% 0.77 Thyroid 629 70% 1.01Rectum 331 43% 0.79 Testis 206 72% 1.02Bladder 364 47% 0.82 Melanoma 853 68% 1.03Ovary 534 54% 0.83

Taksila-Brandt et al Eur J Cancer 2004;40(16):2488-93

Getting back to work (USA)

Most survivors who returned to work did so in the first year

43%

73%78% 81% 84%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-5 6-11 12-23 24-35 36-47

Months after diagnosis

Cumulative percentage returned to work (life-table projections)

Short, Vasey, Tunceli Cancer 2005;103:1292–301

Getting back to work (UK)

• The majority (59%) of those who returned to work managed to do so within 6 months of diagnosis.

• 17% of those who were working before diagnosis were absent from work for more than 1 year (p<0.001)

Amir et al J Cancer Surviv (2007)

Risk factors for delayed RTW

• Older age• More extensive treatment• Heavy physical work• More physical symptoms• Depression• Fatigue• Diagnosis• Lower education• Social class• CNS/head&neck/blood• Female• Co-morbidity

No associations found:• Children in the

household• Marital status• Sleep disturbance• Race

0%

2%

4%

6%

8%

10%

12%

1-11 12-23 24-35 36-47

Months after diagnosis

Cumulative percentage leaving work for reasons related to cancer (life-table projections)

Worked during treatment

Returned in first year

Leaving later

• Of the survivors who returned to work 9-11% would quit for cancer-related reasons in the next 3 years

Short, Vasey, Tunceli Cancer 2005;103: 1292–301

Motivation to resume

• Sick leave …– Boredom– Isolation– Depression

• “I wanted to get back to work as soon as possible .. Work was the normal life I had before and that’s why I focused on it”(Amir Neary Luker Eur J Oncol Nurs 2008)

Pressures to resume

• “With my surgeon’s approval (but not my husband’s), I have returned to work the third week after surgery. I am recovering quickly, and wanted to get back to ‘normal’ as soon as possible.” (Rasmussen & Elverdam Psycho-Oncology 2008;17(12):1232-38) [Den]

• “Since I decided to stop working, my husband pressures me to get a job. I'm scared because if he leaves me I probably won't be able to provide for my children.” (Ashing-Giwa et al J Psychosocial Oncology 2006;24(3):19-51) [USA]

Financial pressures

• “I did not feel quite ready physically and I still felt a bit wobbly mentally and emotionally but I was coming to the end of my full pay and I just couldn’t afford to go onto half pay…”(Amir Neary Luker Eur J Oncol Nurs 2008)

• “I didn’t feel as though I had any choice not to return to work . . . I live alone and I’ve got a mortgage, and at that time I’d got my youngest son still going through university.”(Kennedy et al Eur J Cancer Care 2007;16:17-25)

Loss of employment

• “I lost my job after 6 months... their excuse was that because I could do limited lifting after my lumpectomy, they didn’t have “light duties” for me to do. That was a load of rubbish and they know it. I had been with my work for 22 years and they dropped me like a stone!!” (Bennett et al Supportive Care In Cancer 2009;17:1057-64) [NZ]

• “I’m afraid to apply for jobs, I’ll be rejected. Cause I would send my resume in, and I’m sure I’ll get an interview, but I go in there with my crutches or a cane”

(Parsons et al Social Science & Medicine 2008;67(11):1826-36) [Ca]

Sustaining support

• “…Everybody forgets what you’ve just gone through. Everybody forgets that you’ve got cancer and you’ve got to muck in like everybody else does….” (Amir Eur J Oncology Nursing 2008;12:190-97)

• “They’d soon forget how tired you get and then you’d just be part of the fixture and fittings, they’d forget all about that and then you’d be exhausted, but they’d be expecting you to perform.” (Kennedy et al Eur J Cancer Care 2007;16:17-25)

Accepting changed capabilities

• “When I went back to work, I said to myself, ‘I’ll show you, I am capable of doing what I did before and I’m capable of doing even more.’ I had a breakdown.” (Maunsell et al Psycho-Oncology 1999;8(6):467-73) [Ca]

Evidence-free advice

• 55-yr-old return to manual work following inguinal hernia repair1

– advice from GPs 2 – 16 weeks– advice from surgeons 2 - 12 weeks

• carpal tunnel surgery2

– advice from surgeons 1 – 36 days– the main predictor for time off was the advice given by the surgeon

…. does this harm patients?

1. Majeed AW et al. BMJ 1995;311:296.

2. Ratzon N et al.. Occupational Medicine 2006;56(1):46-50

Abdominal hysterectomy

• Some women are fit to work after 3 to 4 weeks and will not be harmed by this if there are no complications from surgery.

• Many women are able to go back to normal work after 6 to 8 weeks if they have been building up their levels of physical activity at home.

Clayton Verow Occup Med (Lond) 2007;57:525-531

Abdominal hysterectomy

RCOG

Clayton Verow Occup Med (Lond) 2007;57:525-531

Abdominal hysterectomy

Consultant advice

UK intervention studies

• Only one up to 2011 (see Wells M et al (2011) CSO Report CZG/2/467)

Maguire, Brooke, Tait, Thomas, Sellwood 1983

[Recent feasibility study (n =13) - Bains et al Cancer Nursing 2011; 34(6): E1-12]

Counselled ControlReturn 32 25No return 10 21

Cochrane review

• Multidisciplinary physical, psychological and vocational interventions do enhance return-to-work for cancer patients

• The vocational component should not be just patient-oriented but should be directed at the work environment (including work adjustments and supervisors) as well.

De Boer et al 2011 Cochrane Collaboration

Patient strategies for resuming after cancer

• Communication and negotiation with employer

• Acknowledging and accepting changed capabilities

• Managing symptoms and rebuilding confidence

• Working smarter

Wells et al Psycho-oncology 2012

Medical: Critical illness

Recommendation 1.1.22:

• Before discharge to home or community care - Give patients information about driving, returning to work, housing and benefits.

[and note NICE referral for long term conditions.]

Evidence-based occupational rehabilitation

• Occupational outcomes improved by (increasing) activity, including early return to (some) work.

• Rehabilitation is more effective if all take responsibility and play their part when appropriate.

• Communication leads to faster return to work.

• Temporary provision of modified work reduces increases return to work rates.

Many patients work

0%

10%

20%

30%

40%

50%

60%

0-19 20-39 40-59 60-79 80+

The Christie: Outpatients

• ~10000 outpatients of working age

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

15-29 30-44 45-59 60-74 75-89

The Christie: Inpatients

• ~5000 inpatients of working age

• Many cancer patients work• Illness jeopardises employment• Resuming work is a critical outcome of care

• Evidence-based advice and support for resumption of work is an integral part of care

Summary

Work and cancer

Dr Richard PreeceConsultant in occupational medicine

Fellow, National Institute for Health and Clinical Excellence